This coming year, the first of the baby boomers (that massive post-War World II generation) will turn 65. As they have done with all other milestones, the "boomers" will likely transform the way aging is perceived, and how health and aging services will be delivered. Hospice and palliative care services will be essential to meet the needs of this population.
This past week I attended a forum in Washington to kick off the re-authorization of "The Older Americans Act of 1965". The Act established the Federal Administration on Aging as well as State and Area Agencies on Aging (all together these agencies are referred to as "The Aging Network"). Among its many provisions, the Act supports nutritional services (congregate and meals on wheels programs), nursing home ombudsman programs, home health aides and legal services for vulnerable elders. The Aging network leverages funds from Medicaid and Medicare as well as other government programs to expand the range of services it provides. As the Act is re-authorized, there is an opportunity for us to influence the future direction of the network to include a greater focus on hospice and palliative care.
Our older population is both growing and changing. Most elders in our community will want alternatives to nursing home placement. Many will want help coordinating care for advanced chronic illnesses in ways consistent with our philosophy. Support for care-givers and elder justice programs will become far greater concerns for policy makers as well. These are community needs that the network will need to address.
Hospice and palliative care has much to contribute to the network of aging services. As the time for re-authorization draws near, we will be sponsoring community discussions and advocating for support for our services in both Washington and Tallahassee. So stay tuned for notices about these events, and the opportunity to advocate for hospice in re-authorization.
~ HT
Other links:
Florida Department of Elder Affairs
West Central Florida Area Agency on Aging
AARP: Information about the Older Americans Act
Monday, March 1, 2010
Thursday, February 18, 2010
Feeding Tubes in Advanced Dementia
The use of feeding tubes in advanced dementia patients often present difficult emotional, clinical and ethical issues. Family and staff from hospitals, nursing homes and hospices may have very different views on the benefits and burdens of feeding tubes. Several older studies have shown that the use of tubes in these patients does not enhance survival, wound healing or aspiration risk. Two new articles shed some light on the great variation in the use of feeding tubes in different hospitals and nursing homes.
Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment
In this first article , Joan Teno et al. studied over 250,000 nursing home patients with advanced dementia who had been admitted to hospitals. About 20,000 tubes were placed over the 6 years of study but the rates of placement varied dramatically in different hospitals (from 0 tubes to 39 tubes per 100 patients in others). Larger , for-profit hospitals were more likely to have higher tube placement rates. Patients with DNR orders and advanced directives were less likely to get tubes. Once corrected for other factors, being a hospice patient did not seem to influence the tube decision!
Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment
In this first article , Joan Teno et al. studied over 250,000 nursing home patients with advanced dementia who had been admitted to hospitals. About 20,000 tubes were placed over the 6 years of study but the rates of placement varied dramatically in different hospitals (from 0 tubes to 39 tubes per 100 patients in others). Larger , for-profit hospitals were more likely to have higher tube placement rates. Patients with DNR orders and advanced directives were less likely to get tubes. Once corrected for other factors, being a hospice patient did not seem to influence the tube decision!
The Influence of Nursing Home Culture on the Use of Feeding Tubes
The next study compared two nursing home with different rates of feeding tube use. The "culture" of the nursing home mattered a great deal in whether tubes were used. The researchers observed residents during mealtimes and concluded that the low use nursing home had higher staff ratios, more training, multi-disciplinary teams assisting families in decision-making and an attitude that residents generally are better off without tubes.
The next study compared two nursing home with different rates of feeding tube use. The "culture" of the nursing home mattered a great deal in whether tubes were used. The researchers observed residents during mealtimes and concluded that the low use nursing home had higher staff ratios, more training, multi-disciplinary teams assisting families in decision-making and an attitude that residents generally are better off without tubes.
So it seems that the use of feeding tubes in advanced dementia patients may depend more on the hospitals and the nursing homes where patients reside than of the characteristics and wishes of the patients and families themselves. We can do allot to make sure that patient and families are fully aware of the benefits and burdens of tube feeding in dementia patients. They will then be in the best position to make decisions for themselves.
Wednesday, February 17, 2010
The Florida Hospice Model and For-Profit Providers
Hospice care in Florida is unique. Our model of care, provided mostly by large community integrated and not-for-profit hospices emerged out of a strong state regulatory structure (the Certificate of Need (CON) process) and a prohibition against new, for-profit providers (7 programs had operated prior to 1978 and were "grandfathered" in). In 2006, the Florida legislature authorized for-profit hospice entities to operate programs in the state but still required them to meet the CON provisions. Since that time, 6 new for-profit programs began operations in Florida.
A new report from the Office of Program Policy Analysis & Government Accountability OPPAGA) http://www.oppaga.state.fl.us/MonitorDocs/Reports/pdf/1009rpt.pdf issued in January compares for-profit and not-for profit hospices on the basis of three quality measures: pain control within 4 days of admission, patient and family assessment of whether the "right" amount of pain medication was given and whether they would recommend hospice services to others. More than 90% of hospices reported meeting the standards set for these quality measures. The results of the study were so positive that it was impossible to distinguish between provider types. So, the question of whether for-profit hospices offer the same high quality hospice care as the not-for-profits has not been answered yet. This is most likely because the three measures reported were not comprehensive enough to detect the differences.
The ability to measure and provide quality health care is becoming a critical concern for all of us. Medicare is increasingly focused on reporting of quality measures as well as developing a payment system based on quality outcomes. Poor care will be reimbursed less, or not at all. One of our goals will be to demonstrate that the Florida model of hospice care has the potential to improve care and influence our entire community. The spectrum of services, information resources, training opportunities, support groups for caregivers and uncompensated care (among many other services) that we provide are central parts of our model. They are rarely offered by for-profit hospice programs. As we move forward with reporting of quality measures to the state we will also offer these "community outcomes" as additional evidence of the value of our model of hospice care.
A new report from the Office of Program Policy Analysis & Government Accountability OPPAGA) http://www.oppaga.state.fl.us/MonitorDocs/Reports/pdf/1009rpt.pdf issued in January compares for-profit and not-for profit hospices on the basis of three quality measures: pain control within 4 days of admission, patient and family assessment of whether the "right" amount of pain medication was given and whether they would recommend hospice services to others. More than 90% of hospices reported meeting the standards set for these quality measures. The results of the study were so positive that it was impossible to distinguish between provider types. So, the question of whether for-profit hospices offer the same high quality hospice care as the not-for-profits has not been answered yet. This is most likely because the three measures reported were not comprehensive enough to detect the differences.
The ability to measure and provide quality health care is becoming a critical concern for all of us. Medicare is increasingly focused on reporting of quality measures as well as developing a payment system based on quality outcomes. Poor care will be reimbursed less, or not at all. One of our goals will be to demonstrate that the Florida model of hospice care has the potential to improve care and influence our entire community. The spectrum of services, information resources, training opportunities, support groups for caregivers and uncompensated care (among many other services) that we provide are central parts of our model. They are rarely offered by for-profit hospice programs. As we move forward with reporting of quality measures to the state we will also offer these "community outcomes" as additional evidence of the value of our model of hospice care.
Tuesday, January 12, 2010
Hospice and Health Reform :Time to Act
We are now entering the final phase of health reform. Leaders in the House and Senate are meeting to reconcile the two versions of health reform legislation. There is much at stake for our community; both opportunities and challenges. On the opportunity side, if reform passes we will be able to offer hospice care togehter with curative care for children enrolled in Medicaid . A demonstration project (in 15 sites) of concurrent care will also allow for hospice care alongside curative care for those eligible for Medicare. Significant funds for pain research and education will be made available. The House version of the bill will reimburse physicians for advance care planning discussions. Many of our patients and their cargivers will have access to health insurance that may not have been avaaible to them in the past.
Our challenges include cuts to Medicare hospice reimbursement and wage index that will threaten financial viability of many smaller hospice programs. We also face additional risk this year at the state level. Due to the severity of the Florid's fiscal crisis, the Medicaid hospice benefit is again being threatened. I have sent out alerts and calls for actions this past week.
It is very important that our representatives hear from the hospice community. Use the link below to:
Make Sure Congress Knows Where We Stand
Take Action!
Our challenges include cuts to Medicare hospice reimbursement and wage index that will threaten financial viability of many smaller hospice programs. We also face additional risk this year at the state level. Due to the severity of the Florid's fiscal crisis, the Medicaid hospice benefit is again being threatened. I have sent out alerts and calls for actions this past week.
It is very important that our representatives hear from the hospice community. Use the link below to:
Make Sure Congress Knows Where We Stand
Take Action!
Thursday, December 31, 2009
Keep the Hospice Certificate of Need Regulation
The Issue:
Contact your state legislators
Communicate your concerns to your legislators by email, letter or phone. Let them know that you are aware of and concerned about the hospice CON issue.
Become more informed
Tell a Friend!
Voice your opinion!
- The Florida "Certificate of Need" or CON process regulates hospice providers and allows only qualified organizations to establish new hospice services, and only in parts of the state where the need for hospice services is not being met.
- Each year the Florida legislature is heavily lobbied to change the CON process in the interests of increasing competition among hospice programs. There have been several attempts to eliminate the CON process altogether.
- The CON regulations has helped Florida develop very strong hospice programs that serve as examples of high quality, access and community service for hospices in the rest of the country.
- Because of their strength through CON regulation, Florida hospices are able to offer comprehensive services, sponsor innovative research, education and community programs - and offer 3 times more charitable care (for those who otherwise would not receive it) than the national average.
- Weakening of the CON could allow a flood of new and inexperienced hospice providers into the state.
- In other states without a strong CON process, there are many examples of hospices that provide poor quality care, place limits on care, inappropriatly use resources.
Contact your state legislators
Communicate your concerns to your legislators by email, letter or phone. Let them know that you are aware of and concerned about the hospice CON issue.
Become more informed
- CON Overview
from Florida’s Agency for Healthcare Administration. - Florida’s Certificate of Need Process Ensures Qualified Hospice Programs
Report from the Office of Program Policy Analysis & Government Accountability (OPPAGA), an office of the Florida Legislature - Hospice CON Primer
a detailed explanation of Florida’s CON process for hospice care.
Voice your opinion!
Prevent Hospice Rate Cuts
Stop the Hospice Rate Cuts…Permanently!
Ask President Obama to Prevent the Hospice Wage Cuts!
Recently, we asked you to contact the White House to thank President Obama for the recent passage of a one-year delay in the implementation of Medicare hospice rate cuts. You also asked the President to act to permanently rescind the rate cut regulation.
Now, Congress again wants to work with the hospice community to protect compassionate and high-quality care for the more than 1.4 million patients and their families who choose hospice each year. Over 200 members of the House and Senate (including both Senators Nelson and Martinez, and each of our representatives: Young Bilirakis, Castor) signed a letter urging the Obama Administration to intervene on behalf of hospices and stop the rate cuts once and for all.
Time is short! The process to rescind the rate cuts must begin soon in order to circumvent the cuts on October 1. If the cuts are reinstated in October, they will be at a much greater rate than previously seen. Contact Congress today, and ask them to sign the letter to President Obama.
Be sure to forward this message to your friends and family, so that they can join you as Hospice Advocates. We have provided tools to help you share this mesage at the top of the page.
As always, thank you for your efforts!
The Issue:
What We Believe:
How you can help:
Communicate your concerns by email, phone or letter.
Become more informed
Ask President Obama to Prevent the Hospice Wage Cuts!
Recently, we asked you to contact the White House to thank President Obama for the recent passage of a one-year delay in the implementation of Medicare hospice rate cuts. You also asked the President to act to permanently rescind the rate cut regulation.
Now, Congress again wants to work with the hospice community to protect compassionate and high-quality care for the more than 1.4 million patients and their families who choose hospice each year. Over 200 members of the House and Senate (including both Senators Nelson and Martinez, and each of our representatives: Young Bilirakis, Castor) signed a letter urging the Obama Administration to intervene on behalf of hospices and stop the rate cuts once and for all.
Time is short! The process to rescind the rate cuts must begin soon in order to circumvent the cuts on October 1. If the cuts are reinstated in October, they will be at a much greater rate than previously seen. Contact Congress today, and ask them to sign the letter to President Obama.
Be sure to forward this message to your friends and family, so that they can join you as Hospice Advocates. We have provided tools to help you share this mesage at the top of the page.
As always, thank you for your efforts!
The Issue:
- Medicare is the main source of reimbursement for over 1.3 million people and their families served by hospices this year.
- Medicare reimburses hospices a daily rate that is the same for all patients regardless of their diagnosis. The rates have been tied to a “wage index” that helps account for regional differences in labor costs. A wage index adjustment was added in 1997, helping ensure that payments were adequate to cover the cost of providing care.
- The Obama administration is moving ahead with a new rule that will eliminate the wage index adjustment over the next 2 years. This will reduce reimbursement to hospice by an average of 3% nationally (Suncoast Hospice will be cut over $2 million dollars next year, $5 million over 3 years).
What We Believe:
- Hospices and hospice patients need your help! It is more important than ever for you to contact your representatives and ask them to intervene.
- Elimination of the wage index adjustment will have a devastating effect particularly for nonprofit hospices across the country.
- Hospice is the choice for many families who want the best and most compassionate care at the end of their lives. Regulations that protect the availability and quality of hospice care should be preserved and enhanced, not eliminated.
How you can help:
Communicate your concerns by email, phone or letter.
- Write a letter to the editor of St Petersburg Times and Tampa Tribune:
- St. Pete Times: http://www.sptimes.com/letters/
- Tampa Tribune: http://www2.tbo.com/news/opinion/ (form is in the bottom right)
- Send an email to the White House
http://www.whitehouse.gov/CONTACT/ - Send a letter to the President urging him to stop the cuts:
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500
(Please include your e-mail address) - Call the White House Comment Line:
202-456-1111
Become more informed
- Administration Move Jeopardizes Hospice Care
press release from the National Hospice and Palliative Care Organization (NHPCO) - Duke Study
recent study documents that people who receive hospice care cost Medicare an average of $2,300 less than those who don’t. - Reimbursement and Access to Hospice Care
memo regarding the issues surrounding the hospice wage index rule.
Preserve the Medicaid Hospice Benefit
The Issue:
How you can help:
Contact your state legislators
Communicate your concerns to your legislators by email, letter or phone. Thank them for their past support for Medicaid and let them know that you are aware of and concerned about the hospice benefit .
Become more informed
Tell a Friend!
Voice your opinion!
- This past year Florida’s Agency for Health Care Administration recommended that the Medicaid hospice benefit be eliminated. The legislature refused to go along.
- Medicaid provides health care to over 3 million poor children, families and disabled seniors (17% of the Florida population). Between 7,000 – 8,000 terminally ill and needy people received hospice care through the Florida Medicaid program this past year.
- Research has shown that hospice care saves money for Medicaid by caring for these patients at home rather than in expensive hospital beds.
- Eliminating the hospice Medicaid benefit will cost the state over 3 million dollars, mostly in increased hospital and diagnostic costs.
- All Floridians should have access to hospice care. Those who receive hospice care through Medicaid are poor people in the final stages of their lives. These people have limited access to medical specialty care. It is especially important to advocate for their needs.
- This year, despite making massive cuts to the Medicaid budget hospice benefit was spared thanks to the collective efforts of our entire community.
How you can help:
Contact your state legislators
Communicate your concerns to your legislators by email, letter or phone. Thank them for their past support for Medicaid and let them know that you are aware of and concerned about the hospice benefit .
Become more informed
- The Financial Impact of the Hospice Medicaid Benefit
study estimates that the Medicaid hospice benefit saved $282 million, about $1,003 per patient, in 2003. - Kaiser Family Foundation State Medicaid Fact Sheets
extensive data on healthcare costs and services in Florida. - Medicaid and Economic Downturns
details the fiscal challenges that states are facing and how Medicaid might be affected - Medicaid Hospice Benefit Savings
Calculates the additional cost to Florida if the Medicaid hospice benefit is eliminated
Tell a Friend!
Voice your opinion!
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